People have been punching holes in each other's skulls, for medicinal purposes or magic, since at least the middle part of the Stone Age. Now, researchers have found what may be the first evidence this complex surgical operation took place in the lost civilizations in the Sahara and Nubia, too.

The surgical procedure known as trepanation is arguably the oldest known medical operation in history, with the earliest known evidence for it found dating to about 12,000 BC in Morocco. A portion of the skull was removed for therapy or thaumaturgy — for instance, to reduce pressure within the skull, or to release evil spirits.

Scientists now reveal the Garamantians — a lost civilization in what is now southwest Libya — apparently practiced trepanation, the first time the operation has been seen in the Sahara. The Garamantians, named after their capital, Garama, flourished in the harsh central Sahara for nearly 1,500 years between 1,000 BC and 700 AD. They introduced key innovations to the region, including cities, irrigated farming, trade across the Sahara and a hierarchical, probably slave-owning society.

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Archaeologists digging near Garama found three male skulls with signs of trepanning, dating from approximately 1 to 700 AD. The regular shape of all these holes suggests they were made intentionally, as do scrape marks seen in certain cases. The location of most of these marks on the left side suggest they might have been caused as the result of violence with right-handed opponents.

All these patients appeared to have survived the surgery, given the presence of newly formed bone in these holes. This suggests the Garamantians had "knowledge of complex surgical procedures," researchers said in the International Journal of Osteoarchaeology.

Archaeologists have also discovered trepanation in the ancient Nubian kingdom of Kerma. The ancient Nubians have long been thought of as rivals to the more prominent Egyptians who lay to the north of their ever changing borders. The close proximity and interaction of these two civilizations have led to the notion that Nubians copied the traditions of the ancient Egyptians, but this new find suggests the Nubians may have surpassed the Egyptians in some areas of technology and medicine.

The Kerma civilization, which dated between 2,500 and 1,500 BC, was located in what is considered to be the most fertile area along the Nile River south of Thebes. It served as the major middleman for trade between Nubian lands and the Egyptian empire.

One skull from Kerma, probably dating to between 1750 and 1550 BC, had a dime-sized circular hole with clear evidence of healing along its inside edge, the first confirmed Nubian case of trepanation to date. Similar holes have been seen on pyramids from the Egyptian Old Kingdom, suggesting a drill was used here, of the kind to hollow out stone sarcophagi.

"If this is true, it would mean that the Nubians had taken an architectural tool, which was probably introduced to them by the Egyptians years before, and adapted it for a much more sophisticated purpose. This would then imply extremely innovative capabilities and an outstanding intellect on the part of the Nubians," the researchers wrote in the International Journal of Osteoarchaeology.